Introduction: Exenteration during multi-visceral and intestinal transplantation is associated with significant blood loss that increases patient instability intra-operatively and may affect the subsequent post-operative course. This is particularly the case for multi-visceral transplantation (MVT) for porto-mesenteric thrombosis (PMVT).
Methods: Embolisation was undertaken in theatre following anaesthesia and placement of lines. Amplatzer arterial plugs (St Jude), either type I (8mm in length) or type II (16–24 mm) were utilised. In the case of full MVT, the plugs occluded both coeliac axis (CA) and superior mesenteric arteries (SMA). In circumstances where the stomach was retained the SMA, hepatic and splenic arteries were occluded and the left gastric artery preserved.
Results: Pre-operative embolisation was performed in 13 patients who have had either MVT, liver/small bowel transplant (LSB), or small bowel/ pancreas/colon transplant (SBP).
Nine of the 13 cases were embolised for severe portal hypertension (PHT). We have compared blood loss and use of blood products in this group to a historical cohort of intestine containing transplants in patients with severe PHT (table 1).
Embolised = 9 Median (range) |
Non-embolised= 22 Median (range) |
P value | |
Blood loss (ml) |
8000 (1395 – 27400) | 15400 (4700 – 66000) | p = 0.04 |
| RBCs (units) | 6 (0 - 32) | 18 (4 - 82) | p = 0.02 |
| FFP (units) | 4 (0 – 26) | 11 (4 – 26) | p = 0.03 |
| Platelets (units) | 0 (0 – 6) | 4 (0 – 11) | p = 0.04 |
| Cryopercipitate (units) | 0 (0 – 10) | 4 (0 – 20) | p = 0.16 |
| Reperfusion lactate (mmol/L) | 4.3 (1.9 – 11.0) | 7.1 (2.6 – 10.7) | p = 0.11 |
By performing embolisation in the operating theatre there was minimal delay in the explant procedure and no increase in the cold ischaemic time.
There was a reduction in intra-operative blood loss, blood products and metabolic instability. One patient undergoing a full MVT for PMVT required no blood products intra-operatively.
There were no complications associated with the embolisation procedure.
Conclusion: We believe that arterial embolisation is a very useful technique to minimize the blood loss associated with severe PHT during intestine containing transplantation. It reduces blood loss, blood products and metabolic instability. The use of arterial plugs substantially reduces the time required for embolisation and the selective occlusion of visceral arterial branches allows for the preservation of the stomach.
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